Department of Reproductive Health and Research (RHR), World Health Organization
Sexually transmitted and other reproductive tract infections
A guide to essential practice
Management of STIs/RTIs
STI case management and prevention of new infections
Many of the above conditions are sexually transmitted and additional steps are required for effective management. Prompt and effective management of STIs reduces the chance of complications for the individual and prevents new infections in the community.
STI case management includes more than diagnosis and treatment. Even when STIs are correctly treated, treatment failure or reinfection commonly occurs. Some people stop taking their medicines as soon as they start to feel better; or they fail to arrange for their sex partners to be treated; or they do not use condoms or abstain from sex during treatment. Drug resistance may also be a reason for treatment failure. Good STI management must always address these issues.
For treatment of STI to be effective, a full curative dose must be taken (this is also true for non-sexually transmitted RTI). Single-dose treatments thus have an important advantage over multidose treatments which must be taken over several days. When single-dose treatment is not available, health care providers should convince patients of the importance of taking all the medicine prescribed. Patients should be told to finish all the medicine even if they feel better after a few days. They should be warned not to share medicines with others or save pills for a later time. Local chemists should be advised not to sell partial doses of antibiotics to patients who cannot afford to purchase a full treatment dose. If treatment is not provided free for patients at the clinic, try to find solutions for patients who cannot afford to purchase the necessary medicines.
Patients should be advised to avoid unprotected sex until they (and any partners) have completed treatment and are free of symptoms. When single-dose treatments are given, they should wait one week. The following is some additional advice related to specific syndromes:
Counselling and education about STI
People may be more likely to adopt safer sexual behaviour following treatment for an STI. Health care providers should thus make the most of each clinic visit as an opportunity to promote prevention. By discussing the likely circumstances in which the STI may have been acquired, patients can be encouraged to consider safer behaviour that might protect them from infection in the future. Counselling on prevention should always include discussion of the complications of STIs—including infertility and increased risk of HIV infection—as well as condom promotion, demonstration of how to put on a condom and advice on safer sex (Chapter 4).
Partner management (notification, referral and treatment)
A person who is successfully treated for an STI will experience relief of symptoms, but may return later with a reinfection if sexual partners are not also treated. Such partners may or may not have symptoms and, if untreated, may continue to spread infection to others in the community. It is thus extremely important to find ways to help patients notify their partners and arrange for treatment (partners may include not only current partner(s) but all partners within the last three months).
There are several ways that health care facilities can assist with partner notification:
In general, partners should be treated for the same STI as the index patient, whether or not they have symptoms or signs of infection.
Not all RTIs are sexually transmitted, however, and this can complicate matters. Care must be taken not to mislabel or stigmatize someone as having an STI when the diagnosis is not clear. Women with vaginal discharge, for instance, usually have endogenous vaginal infection that is not related to STI. Attempting to notify and treat sexual partners would be both unnecessary (partners do not need treatment) and potentially damaging to their relationship—distrust, violence and divorce are possible consequences of partner notification. Health care providers should therefore be as sure as possible about the presence of an STI before notifying and treating partners, and should recognize that other explanations are possible for most RTI symptoms. Table 8.2 summarizes partner management and counselling messages for common STI/RTI syndromes.
Table 8.2. Partner notification management strategies by syndrome
Special care is required in notifying partners of women with lower abdominal pain who are being treated for possible pelvic inflammatory disease. Because of the serious potential complications of PID (infertility, ectopic pregnancy), partners should be treated to prevent possible reinfection. It should be recognized, however, that the diagnosis of PID on clinical grounds is inaccurate, and the couple should be adequately counselled about this uncertainty. It is usually better to offer treatment as a precaution to preserve future fertility than to mislabel someone as having an STI when they may not have one.
Which sexual partners should be notified and offered treatment? This depends on the incubation period of the STI, the duration of symptoms and the stage of disease. General guidelines for some common STI syndromes and specific STIs are presented in Table 8.3.
Table 8.3. Recommended partner treatment schedule
a. These periods are estimates only and providers should keep an open mind. In most cases where the infection is likely to be sexually transmitted, the last sexual partner should be treated even if the last sexual contact was outside the likely period of infection.
Follow-up visits, treatment failure and reinfection
Are follow-up visits really necessary? It can be useful for health care providers to see some patients again, to find out whether treatment relieved symptoms and achieved a clinical cure. Routine follow-up visits can be an inconvenience for patients, however, and an unnecessary burden on busy clinic staff. Syndromic management provides effective treatment for the most common STIs/RTIs and most patients will get better quickly. It is usually not necessary to have them come back just for a “check up” if they have taken their medicine and are feeling better. However, it is a good idea to advise patients to come back if no improvement is seen after a week of treatment (2–3 days for PID). Patients with genital ulcers should be encouraged to return after 7 days, because ulcers often take longer to heal (treatment should be extended beyond 7 days if ulcers have not epithelialized—formed a new layer of skin over the sore).
When patients with an STI/RTI do not get better, it is usually because of either treatment failure or reinfection. Try to decide which by asking the following questions:
Also consider the possibility of drug resistance. Was treatment based on the national treatment guidelines? Are cases of treatment failure increasing?
Recurrence is also common with endogenous vaginal infections, especially when underlying reasons (douching, vaginal drying agents, hormonal contraceptives) are not addressed. See Chapter 2 for more information on ways to prevent endogenous infections.
Box 8.2 may help you decide what to do in those cases where symptoms do not improve. Remember, flowcharts are not perfect—some patients may need to be referred.
Box 8.2. Treatment failure or reinfection—what to do at the follow-up visit
a. For treatment failure, consider re-treatment with another treatment option. Refer if symptoms persist.
b. For re-exposure during treatment, consider re-treatment with same antibiotics. Refer if symptoms persist.
Infections of the male and female reproductive tract and their consequences:
Preventing STIs/RTIs and their complications
STI/RTI education and counselling
Promoting prevention of STI/RTI and use of services
STI/RTI Assessment during Routine Family Planning Visits
STI/RTI Assessment in pregnancy, childbirth and the postpartum period
Management of symptomatic STIs/RTIs
STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period
Annex 1. Clinical skills needed for STI/RTI
Annex 2. Disinfection and universal precautions
Annex 3. Laboratory tests for RTI
Annex 4. Medications